Urinary Incontinence

What is Urinary Incontinence (Urine leakage)?

Urinary incontinence is an important health problem, especially affecting 30-40% of women over the age of 30. As a result of its frequent occurrence in the society, it is perceived as almost a part of normal life. Women try to solve this problem by using absorbent pads, carrying extra underwear or reducing fluid intake. The number of women seeking professional help for this issue is lower than expected due to both the acceptance of this condition as part of normal life and the embarrassment it causes.

Therefore, women with urinary incontinence plan their daily lives around this problem and their quality of life is severely restricted. Psychological problems such as sexual issues, lack of self-confidence, anxiety and depression are more common in women with incontinence.

However, in parallel with the development of modern medicine and surgical techniques, incontinence can be successfully treated in women. Studies have shown that a significant improvement occurs in the overall quality of life, self-confidence and sexual life of women after treatment. As a result, urinary incontinence in women is not a part of normal life, but a treatable disease.

What is Urinary Incontinence? What are the Symptoms?

Urinary incontinence is defined as involuntary urination or loss of bladder control and is a very common health problem.

It is more common in women. Although its severity varies, it can occur during coughing, laughing or when intra-abdominal pressure increases (stress incontinence) as well as sudden urge to urinate followed by involuntary urination (urge incontinence). Sometimes both types of urinary incontinence can be combined (mix-type incontinence).

If the degree of urinary incontinence affects daily life and quality of life, a doctor should be consulted. In most patients, improvement can be achieved and incontinence can be treated with simple lifestyle changes and simple medical treatments.

Types of Urinary Incontinence

Stress incontinence: This type of urinary incontinence is defined as loss of urine when sudden intra-abdominal pressure increases, such as coughing, sneezing, sudden standing up, laughing, or lifting something heavy. Stress incontinence is seen in the bladder and urethra (the duct opening out of the bladder) as a result of weakness or failure of the valves. The most important risk factor is pregnancy, childbirth and menopause.

Urge incontinence: It is defined as the urinary incontinence with a sudden urge to urinate. It occurs as a result of involuntary contractions that appear suddenly in the bladder and urinary leak occurs before the person reaches the toilet. With the inconvenience of this type of incontinence, the patient goes to the toilet very often, including at night. Among the causes of urge incontinence; diseases such as urinary tract infections, bladder irritations (stone or sand in the urinary tract), bowel problems, Parkinson’s disease, Alzheimer’s disease, stroke and multiple sclerosis. Urge incontinence is also called hyperactive bladder syndrome if there is no underlying disease.

Overflow incontinence: The patient cannot perceive the sensation of a full bladder. Although the bladder is full, there is no sensation to prompt urination, therefore overflow incontinence occurs when urine is stored in volumes exceeding the capacity of the bladder. This type of incontinence occurs in diseases such as bladder injuries, urethral obstruction or diabetes, spinal cord injuries or multiple sclerosis that cause damage to the nerves.

Mixed incontinence: Some women may have a combination of urge and stress incontinence. In this case, incontinence is classified as mixed type.

Total incontinence: It defines urinary incontinence day or night, continuously or periodically.

When should you consult a doctor?

Complaints about urinary incontinence should be reported without feeling any embarrassment during the doctor’s examination. Because this situation is not something to be ashamed of or a part of normal life.

However, if there are following conditions, a doctor should be consulted without delay:

  • If you have serious urinary complaints along with urinary incontinence (blood in the urine, burning, difficulty in urination)
  • If urinary incontinence affects your daily activities, social relationships, quality of life and daily plans
  • If urinary incontinence complaints increase over time

What are the Conditions that can Cause Temporary Urinary Incontinence?

Alcohol: It can cause incontinence due to its stimulating effect on the bladder and its ability to increase urination.

Excessive fluid intake: Too much fluid intake in a short time may cause incontinence due to increased urine production.

Caffeine: It can cause incontinence both by increasing urine production and by direct stimulation of the bladder. Excessive consumption of caffeine-containing beverages such as tea, coffee and energy drinks may be the cause of incontinence.

Bladder stimulants: Carbonated drinks, tea and coffee (with or without caffeine), sweeteners, corn syrup, spicy foods and beverages, sugary and acidic foods, fruits and vegetables such as tomatoes and lemons can induce temporary incontinence by directly stimulating the bladder.

Medicines: Some medications, such as heart medications, hypertension medications, tranquilizers, and muscle relaxants can cause urinary incontinence during use.

Urinary tract infections: Infections can directly cause urinary incontinence by irritating the bladder. Along with incontinence, burning may occur when urinating and foul-smelling, dark urine may be seen. Incontinence improves with the treatment of infection.

Constipation: The rectum and bladder are neighbors and these organs are controlled by similar nerves. In cases of compact hard stool or constipation, an increase in the frequency of urination or hyperactive bladder syndrome may occur, they can sometimes can cause overflow urinary incontinence.

What Are The Conditions That Can Cause Continuous Urinary Incontinence?

Pregnancy and childbirth; Incontinence may occur due to rapidly increasing weight gain during pregnancy, hormonal changes, enlargement of the uterus and pressure on the bladder. In addition, persistent urinary incontinence may occur due to weakening and tears in the pelvic muscles caused by pressure on the pelvic muscles during vaginal delivery. During childbirth, damage to the muscles, nerves and supporting tissues of the pelvis may lead to sagging (prolapse) in the pelvis and vagina.

Prolapse (sagging); The bladder, uterus, rectum, and sometimes small intestines can protrude out of the vagina, and this type of prolapse can also lead to urinary incontinence.

Age-related changes; With increasing age, the storage capacity of the bladder decreases and hyperactive bladder symptoms increase. These complaints are more pronounced especially in elderly women with systemic disease. Quitting smoking, maintaining an active lifestyle, doing sports and controlling diseases such as hypertension and diabetes with treatment can reduce or prevent age-related hyperactive bladder complaints. Due to the decreased estrogen hormone levels in the menopausal period, the tendency to urinary incontinence increases as the blood supply to the bladder and urethra diminish. Interestingly, however, estrogen treatments given after the menopause may exacerbate urinary incontinence.

Hysterectomy (removal of the uterus surgically); the uterus and the bladder are in close proximity and the muscles and fibers that support the uterus also support the bladder. Surgical removal of the uterus may result in urinary incontinence as a result of weakening of the supporting tissues of the bladder and the pelvic muscles.

Painful bladder syndrome (interstitial cystitis); It is characterized by a chronic painful and frequent urination of unknown cause, and can sometimes lead to urinary incontinence.

Bladder cancers and urinary tract stones; urinary incontinence, an urgent need to go to the toilet and a burning sensation during urination may be signs of urinary tract stones and bladder cancers. It can also cause blood in the urine and pain in the pelvis.

Neurological diseases; Multiple sclerosis, Parkinson’s disease, stroke, brain tumors and spinal cord injuries can cause damage to nervous conduction of the bladder, resulting urinary incontinence.

Blockage and compression; Tumors and masses originating from different organs in the abdomen that compress the urinary tract (from kidneys to urethra) can cause overflow incontinence. Stones in kidney, bladder and urinary tract can cause overflow incontinence with the same mechanism.

Risk Factors of Urinary Continence

Gender; Urinary incontinence is more common in women because they are more susceptible to incontinence due to their anatomy, pregnancy, childbirth and menopause.

Age; As the age progresses, the frequency of incontinence increases because of weakness in the bladder muscle structure and pelvic floor muscles. However, incontinence is not considered normal as a natural process of aging, the quality of life can be improved by treating it.

Obesity; Incontinence may develop as a result of increased pressure on the bladder and pelvic floor muscles with excess weight gain. As a result of weakened pelvis muscles, stress incontinence triggered by coughing and sneezing is common.

Smoking; Chronic cough that is associated with smoking and constantly increased intra-abdominal pressure especially increases the risk of stress incontinence. In addition, smoking can affect bladder contractions, causing overflow incontinence.

Systemic diseases; Systemic diseases such as kidney diseases and diabetes increase the risk of incontinence.

What are the Complications of Urinary Incontinence?

Skin problems; Urinary incontinence causes constant exposure of the skin of the genital area to urine and rashes, redness, ulcers (sores) may occur in the genital area.

Urinary tract infections; Incontinence can cause recurrent urinary tract infections.

Changes in daily activities; Incontinence limits daily activities, including recreational ones, due to the individual’s concern about finding restrooms when in urgent need.

Changes in working life; Urinary incontinence negatively affects working life. It prevents participation in long meetings, causes stress and distress on the person, leading to concentration problems. It can also cause fatigue and tiredness due to interrupted sleep at night.

Changes in quality of life; Incontinence can negatively affect the quality of life. Decrease in self-esteem and avoidance from sexual activity can be observed with the fear of incontinence during sexual intercourse. In addition, diseases such as anxiety and depression can be observed more frequently in women with incontinence.

Diagnosis

The most important factor in the diagnosis of urinary incontinence is the patient’s history. The type and severity of incontinence can be determined from the person’s story by investigating the onset of incontinence, its severity and frequency and its effect on the quality of life.

Apart from the medical history, there are a number of specific and non-specific tests that can help diagnose:

Bladder diary; It is a form that contains daily intake of fluids and urination frequency and amount of the urine output. The records are kept for about 1 week and the person’s urination profile and the degree of incontinence are determined.

Urine analysis; With urine analysis, findings related to urinary tract infections and urinary blood or stone can be detected.

Blood tests; Although blood tests are not directly useful for the diagnosis of incontinence, they can be useful for investigating systemic diseases such as diabetes that can cause incontinence.

Post-void (after urination) residual measurement (PVR); It is the process of measuring the urine remaining in the bladder by a doctor with a thin catheter or ultrasound after the person urinates. The presence of excess urine remaining in the bladder after urination indicates an obstruction in the urinary tract, a problem in the urinary tract or in the nerve or muscle layer of the bladder.

Pelvic ultrasound; With ultrasound, bladder capacity and anomalies, tumors, stones and obstructions in the kidneys, bladder and urinary tract can be detected.

Stress test; During the gynecological examination, it is a simple but important test based on the principle of observing whether there is urinary incontinence by increasing the intra-abdominal pressure by coughing or straining.

Urodynamic tests; These tests are based on the measurement of pressure in the bladder during rest and voiding. These tests require special pressure gauges and catheter placement in the urethra and bladder. Although it is not always necessary for the diagnosis of incontinence, it can help with treatment options, especially in patients whose incontinence type cannot be determined.

Cystogram; Problems in the urinary tract can be detected with serial X-ray radiographs taken by applying contrast dye to the bladder.

Cystoscopy; It is a method of direct observation of the bladder and urinary tract by entering through the urethra with a thin cannula containing a camera system. Pathologies in the urinary tract are directly observed and intervention can be performed on lesions during the same session. Although it can be performed even in office conditions, it can also be performed easily under general or spinal anesthesia in operating room conditions.

How Is Urinary Incontinence Treated?

Urinary incontinence treatment depends on the type and severity of incontinence.

Various medical and surgical treatments are available and treatment should be tailored specifically for the patient.

In most patients, physical and behavioral therapies are preferred in the first step. In the next steps, surgery and combined treatments can be preferred in patients with severe anatomical problems and severe incontinence.

Behavioral Techniques in the Treatment of Urinary Incontinence

Behavioral techniques and changes in lifestyle are often useful in the treatment of incontinence, and many patients do not require any further treatment.

Bladder exercises: Bladder exercises include the technique of delaying urination and training the bladder by holding urine for a certain period of time when urge to pee emerges. When the need to urinate arises, urination is started by holding it for 10 minutes first and delaying it. The goal here is to extend the intervals to go to the toilet up to 2-4 hours. Bladder exercise also includes interrupting the urination and keeping urine for a while and urinating again.

Scheduled toilet exercises: Defines timed urination. Bladder training is done by going to the scheduled restroom visits every 2-4 hours.

Fluid intake and diet management: Reducing intake of alcohol, acidic liquids and foods and consumption of caffeinated liquids. In some patients, incontinence problem can be overcome by reducing fluid consumption, weight loss, physical exercise and lifestyle changes.

Physical Therapies for Urinary Incontinence

Pelvic floor muscle exercises: Special exercises, including pelvic floor muscles and bladder facilitate urine control. Continence can be achieved with periodic physiotherapy sessions. Pelvic floor exercises such as “Kegel exercises” are based on the principle of trying to stop or slow down the flow of urine while peeing and performing voluntary contraction of the pelvic muscles. During urination, pelvic muscles are squeezed and urination is stopped while counting up to three and then resumed, and this is repeated periodically. It is important to work out the correct muscles when practicing Kegel exercises. Correct use of pelvic floor muscles involves not using the abdominal and leg muscles. In order for Kegel exercises to be performed effectively, they should first be practiced with a physician and physiotherapist, and when the patient learns to work out the correct muscle groups, they should be continued as an individual self-treatment.

Electrical stimulation: It is a treatment method based on placing the electrodes in the pelvic floor muscles around the vagina and rectum. These muscle groups contract with electrical stimulations. Although electrical stimulation is an effective treatment method in stress and urge incontinence, many sessions are required and treatment lasts for months.

Drug treatment of urinary incontinence

Pharmacological treatments are often used in combination with behavioral and physical treatments. The drugs to be chosen may vary from patient to patient and can sometimes be used in combination. Drug use must be selected by a doctor and continued under the supervision. All drugs can have serious side effects.

The main drug groups used are:

Anticholinergic: This group of drugs is often used in urge incontinence therapy, hyperactive bladder syndrome and mixed type incontinence. Drugs in this category include oxybutynin, tolterodine, darifenacin, fesoterodine, solifenacin and trospium. Side effects of these drugs may include dry mouth, constipation, blurred vision, and hot flashes.

Local estrogen creams and tablets: Locally administered estrogenic vaginal creams and tablets may be effective in the treatment of incontinence by increasing cell renewal and tissue nutrition in the genital area and urinary tract.

Imipramine: Imipramine is an antidepressant and is used in stress incontinence and urge incontinence, as well as in cases of nocturnal enuresis (nighttime urinary incontinence in children).

Duloxetine: It is a new generation antidepressant and used for stress incontinence in selected patients.

Medical Tools in the Treatment of Urinary Incontinence

Various medical tools and devices are used in the treatment of incontinence, but their place in the treatment is limited.

Urethral inserts in the form of mini buffers can prevent urinary incontinence by closing the urethral outlet, but use for longer than 24 hours is inconvenient. Urethral inserts can be used during heavy physical activities, however their routine use is quite limited. Nevertheless, especially in patients with vaginal prolapse (sagging), vaginal ring-shaped silicone pessaries can be used. A pessary is inserted into the vagina, supporting both the pelvic floor muscles and lifting the bladder, contributing to the treatment of incontinence. However, long-term use of pessaries may cause ulcers in the vagina and infection, so it is necessary to discontinue its use for certain periods.

Surgical Applications in Treatment

Synthetic material injections: Some synthetic materials such as carbon-coated zirconium, calcium hydroxyapatite, polydimethylsiloxane are injected under and around the urethra. The support under the urethra holds up the tissue and bladder neck, preventing the incontinence. It is a very easy technique and can be applied with a local anesthesia in 5 minutes under office conditions, but the intervention should be repeated frequently in certain periods. Success rates are around 60%.

Botulinum toxin type A: Botox application to the muscle layer of the bladder is especially useful in hyperactive bladder syndrome and urge incontinence. However, if too much Botox is applied, the patient may have difficulty in urinating. It should be repeated every 6-9 months.

Nerve stimulating devices: These are devices that stimulate the sacral nerve, which is responsible for bladder nerve impulses, and nerve stimulators that can be applied to the leg and hip, however their use is extremely limited.


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